REC-M-0028-Equipment of Medical Backpacks in Mountain Rescue

IKAR
Rec M 0028
International Commission for Alpine Rescue
Commission for Mountain Emergency
Medicine (ICAR MEDCOM)
Equipment of Medical Backpacks in Mountain
Rescue
OFFICIAL RECOMMENDATION OF THE INTERNATIONAL COMMISSION FOR
MOUNTAIN EMERGENCY MEDICINE (ICAR MEDCOM)
Fidel Elsensohn,1 Inigo Soteras,2 Oliver Resiten,3 John Ellerton,4 Hermann Brugger,1,5 and
Peter Paal6
1: International Commission for Mountain Emergency Medicine (ICAR MEDCOM), Austrian Mountain
Rescue Service, Roethis, Austria.
2: GRAE, Bombers de la Generalitat de Catalunya, Department of Emergency and Internal Medicine,
Cerdanya Cross-Border Hospital, Puigcerda, Spain.
3: Kantonale Walliser Rettungsorganisation (KWRO), Air Zermatt, Switzerland.
4: Mountain Rescue Council England and Wales, Penrith, United Kingdom.
5: Institute for Mountain Emergency Medicine (EURAC), Bolzano, Italy.
6: Mountain Rescue Service of South Tyrolean Alpine Association, Department of Anesthesiology and
Critical Care Medicine, Innsbruck Medical University, Innsbruck, Austria.
This article reflects the consensus of opinion of the International Commission for
Mountain Emergency Medicine which has full responsibility for the content.
Reprintet from HIGH ALTITUDE MEDICINE & BIOLOGY Volume 12, Number 4, 2011
© Mary Ann Liebert, Inc. DOI: 10.1089/ham.2010.1048
HIGH ALTITUDE MEDICINE & BIOLOGY
Volume 12, Number 4, 2011
ª Mary Ann Liebert, Inc.
DOI: 10.1089/ham.2010.1048
Equipment of Medical Backpacks in Mountain Rescue
Fidel Elsensohn,1 Inigo Soteras,2 Oliver Resiten,3 John Ellerton,4 Hermann Brugger,1,5 and Peter Paal6
Abstract
Elsensohn, Fidel, Inigo Soteras, Oliver Reisten, John Ellerton, Hermann Brugger, and Peter Paal. Equipment of
medical backpacks in mountain rescue. High Alt. Med. Biol. 12:343–347.—We conducted a survey of equipment in
medical backpacks for mountain rescuers and mountain emergency physicians. The aim was to investigate
whether there are standards for medical equipment in mountain rescue organizations associated with the International Commission for Mountain Emergency Medicine (ICAR MEDCOM). A questionnaire was completed
by 18 member organizations from 14 countries. Backpacks for first responders are well equipped to manage
trauma, but deficiencies in equipment to treat medical emergencies were found. Paramedic and physicians’
backpacks were well equipped to provide advanced life support and contained suitable drugs. We recommend
that medical backpacks should be equipped in accordance with national laws, the medical emergencies in a given
region, and take into account the climate, geography, medical training of rescuers, and funding of the organization. Automated external defibrillator provision should be improved. The effects of temperature on the drugs
and equipment should be considered. Standards for training in the use and maintenance of medical tools should
be enforced. First responders and physicians should only use familiar tools and drugs.
Key Words: Emergency medical service; medical equipment; mountain rescue; prehospital emergency care;
backpack
Introduction
M
ountain rescue teams are trained to treat patients
according to international standards (Anonymous,
2005), but treatment in remote and mountainous areas can be
limited by personnel and equipment. In most situations, a
medically trained mountain rescuer acts as first responder on
Basic Life Support (BLS) level before an emergency physician
or a paramedic will provide Advanced Life Support (ALS)
treatment. The contents of a medical backpack are determined
by many factors, such as national laws, funding, medical
training of rescuers, common medical emergencies of a
given region, and personal preference. Difficult terrain, harsh
weather conditions, and long access and evacuation times
require light and space-saving equipment. Backpacks are
more in use now than hand-carried bags because they are
more comfortable to carry and allow the rescuers’ hands to be
free which is important in difficult terrain. Recently, the injury
patterns of mountain casualties (Hearns, 2003), the status of
mountain rescue services (Brugger et al., 2005), and medical
training in mountain rescue (Elsensohn et al., 2009) have been
reported. However, neither an overview, nor recommendations exist on which medical equipment should be employed
in the treatment of mountain casualties. The purpose of this
study was to evaluate the contents of medical backpacks designed for terrestrial missions in mountain rescue organizations associated with the International Commission for
Mountain Emergency Medicine (ICAR MEDCOM) and to
give recommendations regarding medical equipment.
Aims and Methods
A standardized questionnaire was distributed and collected in 2006 among ICAR MEDCOM representatives. This
1
International Commission for Mountain Emergency Medicine (ICAR MEDCOM), Austrian Mountain Rescue Service, Roethis, Austria.
GRAE, Bombers de la Generalitat de Catalunya, Department of Emergency and Internal Medicine, Cerdanya Cross-Border Hospital,
Puigcerda, Spain.
3
Kantonale Walliser Rettungsorganisation (KWRO), Air Zermatt, Switzerland.
4
Mountain Rescue Council England and Wales, Penrith, United Kingdom.
5
Institute for Mountain Emergency Medicine (EURAC), Bolzano, Italy.
6
Mountain Rescue Service of South Tyrolean Alpine Association, Department of Anesthesiology and Critical Care Medicine, Innsbruck
Medical University, Innsbruck, Austria.
2
343
344
ELSENSOHN ET AL.
study analyzed only the contents of medical backpacks and
did not ask how frequently technical and medical devices are
used. The results and recommendations were discussed
among the authors, and presented at the ICAR MEDCOM
meetings in Chamonix, France, in October 2008 and in Bansko,
Bulgaria, in March 2009. Finally, the ICAR MEDCOM approved the recommendations in Zermatt 2009. Nominal data
are given as counts (percentages). Figures were arranged with
Excel 2008 (Microsoft, Seattle, WA).
Results
Eighteen mountain rescue organizations from 14 countries
in North America and Europe returned the questionnaire
(Table 1). Sixteen organizations provide a special medical
backpack for mountain rescuers who are acting as first responders, whilst all 18 organizations provide a special medical backpack for mountain rescue physicians. The contents
of the mountain rescuers’ medical backpacks are shown in
Figure 1. Eight of 16 (50%) backpacks are equipped with oral
nitroglycerin, five (33%) contain oral analgesics, but seven
(43%) backpacks contain no drugs. Medical equipment in
medical backpacks of mountain rescuers is defined by law
in two (12%), by internal or national standards in 10 (63%),
and by no specific standards in four (25%) organizations.
The contents of the mountain rescue physicians’ medical
backpacks are shown in Figures 2 and 3. Their content is defined by law in three of 18 (17%), by internal standards in 13
(72%), and by no specific standards in two (11%) organizations. These backpacks always stay with the mountain rescue
physician in 12 (67%) organizations, whilst in the remaining
six (33%) organizations the backpack is brought to the scene
independently of the mountain rescue physician, just in case
another physician reaches the scene first. Drugs are provided
and maintained by the mountain rescue physician in 13 (72%)
organizations.
Table 1. Mountain Rescue Organizations
Participating in the Survey
Country
Austria
Austria
Austria
Bulgaria
Canada
Canada
Croatia
England
Germany
Italy
Norway
Poland
Slovenia
Slovakia
Slovakia
Spain
Switzerland
United States
of America
Organization
Mountain Rescue Salzburg
Mountain Rescue Styria
Mountain Rescue Vorarlberg
Mountain Rescue Service
Canadian Ski Patrol
Canadian Mountain Holidays
Mountain Rescue Service
Mountain Rescue Council
Bergwacht
Corpo Nazionale Soccorso
Alpino e Speleologico
Mountain Rescue Service
Polish Mountain Rescue (TOPR)
Mountain Rescue Service
HSNS Mountain Rescue Service
HZS Mountain Rescue Service
Mountain Rescue Service
Kantonale Walliser
Rettungsorganisation (KWRO)
Mountain Rescue Association (MRA)
FIG. 1. Medical equipment of first responders’ backpacks
(organizations n = 16; chart limited to equipment with > 1
item).
Discussion
In terrestrial rescue, the physician is frequently not the first
rescuer on the scene. Trained mountain rescuers, acting as
first responders, will perform the initial assessment and maneuvers such as BLS, splinting, wound dressing, and protecting the patient from further heat loss. In some countries
these first responders may be paramedics, mountain guides
(e.g., in North America) or casualty care certified mountain
rescuers (e.g., in United Kingdom) able to give a restricted
range of drugs.
In such a circumstance, these drugs may become part of the
mountain rescuer’s backpack (Arntz et al., 2010; Ellerton,
2006). Thus, most organizations have tailored their medical
backpacks into one for trained mountain rescuers and one for
physicians. The degree to which these backpacks are complimentary, thus avoiding weighty duplication, will depend
on the organization’s necessities. All monitored medical
backpacks for mountain rescuers are equipped with medical
equipment for trauma therapy. In contrast, only eight of 16
(50%) organizations provide an Automated External Defibrillator (AED) thus, potentially compromising the management of a primary cardiac arrest. At mass events, rescue
missions in frequented ski resorts, or remote villages with
long access time for ALS providers an AED may potentially
save lives (Elsensohn et al., 2006).
In addition to the mountain rescuers’ backpacks, the physicians’ medical backpacks have equipment to give oxygen,
cannulate a peripheral vein, and administer intravenous
fluids. All backpacks for physicians are equipped with ALS
material according to the International Liaison Committee
On Resuscitation (ILCOR) guidelines (Morrison et al., 2010;
Nolan et al., 2010).
Blood pressure measurement devices are part of all backpacks and pulse-oximetry in 13 out of 18 (72%). The additional
weight of a blood pressure cuff must be evaluated against
other ways of monitoring and clinical findings and the less
weight of a pulse oximetry. However, in cases such as traumatic brain injury (TBI) or permissive hypotension treatment
EQUIPMENT OF MEDICAL BACKPACKS
FIG. 2.
345
Medical equipment of physicians’ backpacks (organizations n = 18; chart limited to equipment with > 1 item)
(Sumann et al., 2009), accurate blood pressure measurement is
mandatory.
Seventeen out of 18 (94%) of the physician’s backpacks have
equipment for tracheal intubation or a supraglottic airway
device (Cook et al., 2006). Mirroring the finding of the rescuers’
backpacks, an AED or a manual defibrillator is less frequently
part of the equipment (8/18, 44%). An ECG is included only in
7/18 (40%) of physicians’ backpacks. A monitoring device with
the possibility of defibrillation should be considered to be part
of every physicians backpack to detect and immediately treat
arrhythmias or other cardiac dysfunctions. This should also be
fact for all medical helicopter operations.
Drugs are limited because of weight and available space. A
minimum drug equipment should include acetylic salicylic
acid, a strong opioid (e.g., morphine) and nitroglycerin (to
treat an acute coronary syndrome) (Arntz et al., 2010); cristalloids/colloids and a vasopressor for shock (Sumann et al.,
2009), and ketamine/midazolam for analgesia/sedation
during procedures (Bredmose et al., 2009; Ellerton et al.,
2009). Hyperosmotic solutions so far did not show improved
FIG. 3. Drugs in physicians’ backpacks (organizations n = 18; chart limited to equipment with > 1 item)
346
ELSENSOHN ET AL.
Table 2. Recommendations for Mountain Rescuer’s
Medical Backpack
Drugs
Drugs
According to national and internal
regulations, for example, nonsteroidal antiinflammatory drugs (e.g., acetylsalicylic
acid, diclofenac, ketoprofene), morphine,
nitroglycerin
Medical equipment
Intravenous line set and infusions (e.g.,
500 mL crystalloid)
Miscellaneous Adhesive tape, aluminum blanket, gloves,
equipment
scissors
Monitoring
Blood pressure measurement, pulse oximetry,
epitympanic thermometer
Trauma
Splinting (e.g., cervical collar, SAM splint,
wound dressing
Ventilation
Bag-valve mask, manual suction device,
nasopharyngeal and oropharyngeal tube,
oxygen, pocket mask, Venturi mask
I.V. line
Table 3. Recommendations for Physician’s Backpack
in Mountain Rescue
Advanced life
support
Analgesics
Drugs
Amiodarone, atropine, epinephrine
Strong opioid (e.g., fentanyl, morphine),
ketamine, nonsteroidal antiinflammatory drug (e.g., diclofenac,
ketoprofene)
Sedatives
Ethomidate, midazolam, propofol
Muscle paralytics Rocuronium, suxamethonium
Cardiovascular
Acetylsalicylic acid, beta-blocker,
drugs
fibrinolytic, heparin, nitroglycerin,
vasopressor (e.g., dopamine,
norepinephrine)
Bronchodilators
Beta-agonists (inhalative and i.v.),
corticosteroids (inhalative),
theophylline
Other drugs
Flumazenil, furosemide, glucose 33% or
40%, H1- and H2-receptor antagonists,
naloxone, corticosteroids (i.v.)
I.V. line
Miscellaneous
equipment
Monitoring
Trauma
Ventilation
Medical equipment
Intravenous line set and infusions (e.g.,
500 mL crystalloid), hypertonic fluid
Adhesive tape, aluminum blanket,
gloves, indwelling urinary catheter
and bag, scissors
Blood pressure measurement,
capnography, electrocardiogram,
glucometer, pulse oximetry,
stethoscope, thermometer (esophageal
and epitympanic)
Replantation bag, splinting (e.g., cervical
collar, SAM splint, wound dressing
Alternative airway device (e.g., laryngeal
mask), bag- valve mask, manual
suction device, nasopharyngeal and
oropharyngeal tube, oxygen,
thoracotomy set, tracheal intubation
set (plastic laryngoscope scoop
preferable with cold weather, Venturi
mask
outcome of traumatic hypovolemic shock and severe TBI
(Bulger et al., 2011; Rockswold et al., 2009) but may reduce
weight. Also their considerable volume effect may be advantageous in mountain rescue missions (Kreimeier et al.,
2002; Nolan, 2001). The storage and operating environmental
temperature of equipment and drugs should be considered
(Kupper et al., 2006). The specialization of a physician influences the backpack contents in many instances. For example,
an anesthesiologist’s backpack, when compared to one of a
general physician, may contain more advanced airway management equipment, hypnotics, and muscle relaxants.
Oxygen is a universal part when treating patients with
medical and trauma emergencies, yet only six of 16 mountain
rescuers’ backpacks contain it. Frequently, oxygen is in limited supply because of its weight, even when lightweight highpressure cylinders are used (Ellerton, 2006). Techniques to employ oxygen efficiently such as a Venturi mask with a reservoir
(Murphy et al., 2001) or an Oxymizer (www.chadtherapeutics.com/usa/Disposable-Conservers/Oxymizer.html)
allow tailoring the oxygen flow rate to the oxygen saturation
as determined by pulse oximetry (Leach et al., 2009).
The weight of backpacks: monitoring devices range from
490 grams (AED with ECG function) and 2100 g for the
smallest ECG with complete monitoring functions. Physician’s backpacks with all recommended items usually weigh
approximately 12 to 20 kg. Backpacks for first responders
range from 5 to 8 kg.
Limitations
One limitation of this study should be mentioned. First, only
14 out of 21 member countries participated in this inquiry. The
possibility that the questionnaire did not include all drugs or
equipment used by the participating organizations in a defined
area should also be mentioned. A responder bias may be inherent to this questionnaire. Generalization of our data may be
limited, because not all organizations associated with ICAR
MEDCOM participated in this study. According to the aims of
this study, adequacy and usefulness of technical medical devices and drugs have not been evaluated as this would be a task
of another study. We are not recommending a detailed list of
contents as there are no scientific data to evaluate a specific
pattern of injuries under special circumstances in a given area.
Therefore the recommendations are a consensus of experts.
Conclusion and Recommendations
In mountain rescue, medical equipment transported to a casualty has to be restricted to the most essential items because
weight in helicopter emergency medical services is at a premium or during terrestrial rescues the equipment has to be
carried long distances over a prolonged time (Tomazin, 2003).
Medical backpacks should be equipped according to national
laws, medical emergencies in a given region, climate, geography, medical training of rescuers, and funding. Backpacks for
first responders should contain equipment for BLS (Elsensohn
et al., 2006; Paal et al., 2007), splinting (Ellerton et al., 2009),
wound dressing, blood pressure, and temperature measurement. Recommendations for mountain rescuer’s medical backpacks are shown in Table 2. Backpacks for physicians should
enable ALS, and treatment of trauma, anaphylaxis, pulmonary
edema, and hypertensive urgency. Recommendations for physician’s backpack in mountain rescue are shown in Table 3.
However, the contents of a physician’s and paramedic’s back-
EQUIPMENT OF MEDICAL BACKPACKS
pack should be adapted to the skills of a given rescuer. Oxygen,
for example, may be the most important drug in AMS; however
the weight can exceed manpower and the limited capacity may
reduce usefulness. A defibrillator should be considered to be in
every physician’s backpack. In order to save weight, the physician’s backpack should be complementary to the mountain
rescuers’ medical backpack. Standards for training in the use
and maintenance of medical equipment should be enforced
(Elsensohn et al., 2009). Mountain rescuers, paramedics, and
physicians should only use familiar tools and drugs.
Author Disclosure Statement
This study was not supported financially or materially by
any producer of ventilation devices. The authors are not involved in any financial interest and did not get any grants or
patents concerning the described devices.
Acknowledgments
These recommendations have been discussed and officially approved at the ICAR MEDCOM at the meeting in
Chamonix (Switzerland), Bansko (Bulgaria), and Zermatt
(Switzerland) by the following members: Gege Agazzi (I);
Fabian Argewone (F); Sara Batista (E); Marc Blancher (F);
Jeff Boyd (CDN); Bruce Brink (CDN); Hermann Brugger
(I); Vera Buchet (F); Ivana Buklijas (HR); Damien Cabane
(F); Ramon Chiocconi (RA); Rik Decker (ZA); Florian
Demetz (I); John Ellerton (E&W); Fidel Elsensohn, Vice
President (A); Yuuji Hatori ( J); Martin Ivanov (BG), Kenji
Kimura ( J); Tim Kovacs (USA); Xavier Ledoux (F); Werner
Mahrlein (D); Marko Majstorovic (SRB); Scott McIntosh
(USA); Jose Morandeira (E); Maria Antonia Nerin (E); Peter
Paal (I); Mato Poharka (SK); Gula Przemyslaw (PL); Oliver
Reisten (CH); Peter Rheinberger (FL); Jose Santos (E); Haris
Sinifakoulis (GR); Mirom Sorim (RO); Inigo Soteras (E);
Günther Sumann (A); Michael Swangard (CDN); Oleg
Tcholakov (BG); Steve Teale (SCO); Masatoshi Teshima ( J);
Iztok Tomasin (SLO); Claire Vallenet (F); Vlahov Vitan
(BG); Karen Wanger (CDN); David Watson (CDN); Eveline
Winterberger (CH); Isla Wormalo (Eng); Ken Zaffren, Vice
President (USA); and Greg Zen-Ruffinen (CH).
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Address correspondence to:
Fidel Elsensohn
International Commission for Mountain Emergency Medicine
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E-mail: [email protected]
Received July 24. 2010;
accepted in final form May 23, 2011